4 Me ik MR L9 209 REDACTED copy "2G é nian” pptewins DUAGHG a : Donets eter ng Board of Registration in Medicine 200 Harvard Mill Square, Suite 330 - Wakefield, MA 01880 g Telephone: (781) 876-8210 Fax: (781) 876-8383 www.massmedboard.org iy 8 FULL LICENSE APPLICATION 3 nalcaon Es of S000 mae abo h Commonweal of fbechosss thames ee eaonoheae : Cheek One: QR vs icuncian Graduate tmemacionat Graduate ‘Legal Name (do not use nicknames or initials, unless they are pat of your legal name) Drasten _ Kari Patricia as Nane Qe perdu] —— Fi Wile Siwy Jr. 200) Pap fi onercepee_ MPH Cl Mate YY Femate Other Name(s) Used ~ List sny other name(s) you have used which may af ‘on your identifying documents, such as ‘etc edison sd examination eons Ico oplcable check het ET Eni Ta ame oe RATT Fi wae Tae Date of ink: Soci Sear Mamba, ia i Ye riaceorairn_ OSLO Nora. yr CoE *Maliog des: fue ae umber and See City a ‘State/Province/Territory Zip (or postal) Code. ‘Home Address: : : Telephone: et ec a ty San BT EG Tar RO EE pusnessaddies. 15 Franas Sheet Teteprone: (ef) ~ 332-5500 Naira Sree “boston MA O21 oy aProiea aay 2 erbona ae smal Ades a — :Pexronber_ 017-271-1440 : eying be ue eh 7CVSt Gerimeconie 2) Ch Yer Yn “The Board will ue your Mailing Address forall correspondence so CK NATTY SO ie O3/2a/\o We04/07/2010 WED 19:18 FAX o1f27714¢0 opcix panrrwane: KO f cates PAGE2 OF 5 Date of medical schoo! graduation: OS 120 1200S Med toe ‘Note: U.S. graduates must inchade a written explanation forthe durniicn of medical education longe: than four (4) Years, and for any breaks in medical education. Intemational graduates must provide a written explanation forthe ‘uration of medical education longer than six (6) years and any breaks in medical edacation. ostaraduate Edveation: List all postgraduate training in chronological ater from medical schoo! to the present. Inchude the narae nnd address of the facility, your positon, e.g. PGY 1,2, fellow, ci, and dates of wllation. You must account for all, periods of training or postgraduate wouk from the time you graduated from medical school, oor “ a & » olesranrrane: Kari Broaten PAce20F 5s racty: Yale Universe epee: BA Fee 8782/2000 = isp get¢ —— en ive a eS a Facility Degree Street: City) Medical School Facility: ogteyretera On hay eves MD|MPH |B128 0). 870) 200% Street: City: Gucage ‘State: je Feciliy Degree: Sweet: ‘cy: Date of medical school graduation: 5120 ) 2005 — oy ‘Note: U.S. graduates must include a writen explanation forthe duration of medical education longer than four (4) yetrs, and for any breaks in medical education. International graduates must provide a writen explanation for the ‘ration of medical education longer than six (6) years and any breaks in medical education. Postgraduate Education: List all postgraduate traning in chronological onr from medical school tothe present. Include the name and Address of the facility, your position, eg PGY 1, fellow, etc. and dates of affiliation. You mist account fr all Periods of training or postgraduate work from the time you graduated from medica! school. from To Pass Position: Jet BAIR OS [0/31 105- iy: Site: A Position PY I=4 G /20/sb 6 /IR Nolo Beste Suse a City: P Position: Cig Position: Street: a City: Position Street: City: a i fe a Olvezrro §isto Please contact the appropriate examination entity and have certified transcript of your scores sent directly to this Board, If you are using ECVS, your examination scores will be sent to the Board with your credentials packet. List eack licensure examination, U.S. or international, you have taken (USMLE, NBME, NBOME, LMC, Ete.) additional space is necessary, please enclose @ separate sheet with your application and include all the information below. If you answer “'yes" to question 25 on the Full Supplement, you must also complete the required information "ye PAGE 3 of S| Exemination Most Recent Date taken (Month/Year) Passed (P) or Feiled (F) Number of attempts 1 USMLE Step I USMLE Step 11 USMLE Step I NBME Part | NBME Part It NBME Per itt FLEX Component | FLEX Component 2 FLEX Pre-1985 NBOME Part | NBOME Par It NBOME Pan I COMLEX Level | COMLEX Level 2 COMLEX Level 3 COMVEX LMCC - Single LMCC~ Part LMCC — Part IL ‘State Board Exam = 24 200 3] 24] Z00! bf [2007 | Hi (Siate of examination) We We Wr ae Or ae Op Oe Ge Op aoe Gr Op OP oe oP Ge Op Oe OP ar oF OF Or OF OF OF or oF OF OF OF Or oF oF oF OF cr Or ar | ovezrvo &03/31/2010 WED 12:2 Fax 172771440 concen + Street: rant wave Kari Brostey PAGE 40F 5 0 mn ment List hospltl appointments jn chronotiglcal order, where you had active staff privilees. Include the name and address of the facility, your position and dates of affiliation. Also include periods of unemployment or employment outside of medicine, Attach a separate sheet of paper ifnecessary. Te Facility: Faeiliy: Street: Facility: 1. List other states (sbbreviations) where you are currently or have ever had a full license: 2, a) Are you certified by the American Board of Medical Specialties? Yes No b) Are you certified by the American Board of Osteopathle Medicine? Yes No 3, List Board Cenifcation(): Certification diter_/_/__ : Certification dare:__f. 4. List our practice spectanites) DyGletnics sod Gonccslagy 5, Have youetached an uptodate copy of your curiulum ste? IX] Yes CJ No 6. Reason for requesting a Massachusetts medical license: _1 Adéress:_16 Faas Y Street iy: Boston 8. Anticipated starting date ia Massachusans: I_/1__/ 2OLO Under the penalties of perjury, [declare that I have examined this full application and alt its accompanying instructions, forms and statements, and to tic best of my knowledge and belief, the information contained hercin is rue, correct aad complete. As an applicant for a full license to pract medicine, I understand that a criminsl record check may be conducted for conviction and pending ‘criminal case information from the Criminal History Systems Board only and that it will not necessarily disqualify me from 217) 2010 Signature of Applicant Mons Day Year ‘(Continued on pages) fa g 8 aNATIONAL PROVIDER IDENTIFIER (NPL, ‘The primary purpose of the NPI is to uniquely identify health care providers as “health care providers” in HIPAA standard transactions. The NPI will replace all other identifiers assigned to health care providers, such as those assigned by health plans, government programs and health care purchasers for purposes of conducting these business transactions. Under the final HIPAA NPI Rule, all individual and organization covered providers were required to obtain an NPI by May 23, 2007. ‘You must supply the Board of Registration in Medicine with your valid NPI. If you do not have ‘an NPi number, you can apply for an NPI directly by using the NPPES web site at ‘MWLNPPES cms hhs.gov. My current NPI is: CRW DMeIG) Penal ti 18 U.S.C. 1001 authorizes criminal penalties against an individual who in any matter within the jurisdiction of eny department or agency of the United States knowingly end willfully falsifies, conceals or covers up by any trick, scheme or device a material fact, or makes any false, fictitious or fraudulent statements oF representations, of makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of up to $500,000. 18 U.S.C. 3571(¢) also authorizes fines of up to twice the gross gain derived by the offender if itis greater than the amount specifically authorized by the sentencing statute. Please sign and date to confirm that all of the information on this form is true and accurate. Signature: oo S 1112010pant name: Kari Broaber PAGESOF S lations 9 t List hospital appointments, in chronological order, where you had active staff privileges. Include the name and address of the facility, your position and dates of affiliation. Also include periods of unemployment or employment outside of medicine. Amach a seperate sheet of paper if necessary. City: Facility: Position: Sweet: City: Facitiy:_ Position: Street: City: Facility: Position: Street ‘city: 1. List other states (abbreviations) where you are currently or have ever hed full icense: 12. a) Are you cenified by the American Board of Medical Specialties? D ve No b) Are you cenified by the American Board of Osteopathic Mecicine? —). Yes No 3. List Board Centification(s). Certification date; Certification date;_/__f 4. List your practice speciahi(ies) 5. Have you atached an uptodate copy ofyourcuriculum vise? Kf Yes C]_No Under the penalties of perjury, | declare that I have examined this full application and all its accompanying instructions, forms and statements, and o the best of my knowledge and belief, the information contained herein is true, correct and complete. As an applicant for 2 full license to practice medicine, | understand that criminal record check may be conducted for conviction and pending criminal case information from the Criminal History Systems Board only and that it will not necessarily isqualify me from licensure, 3717, 2010 Signature of Applicent Month Day Year (Continued on pages) ° g § 309/91/2010 WED 12:22 FAX 6172773440 ‘oBGeN (CURRICULUM VITAE PART I: General Information DATE PREPARED: March 17, 2010 Name: ‘Kari Patricia Braatea, MD, MPH Office Address: Department of Obstetrics and Gynecology Brigham and Women's Hospital 75 Francis Street Boston, MA 02115 ‘Home Address: E-Mail: Place of Birth: Oslo, Norway Education: 8/2001-5/2005 MD _ Feinberg School of Medicine, Northwestem University, Chicago, IL 8/2001-5/2005MPH Northwestern University, Chicago, IL 8/1996-6/2000BA Women’s Studies, Yale University, New Haven, CT Post-doctoral training: 672006-6/2010 Obstetrics and Gynecology Resideacy Brigham and Women’s & Massachusetts General Hospitals, Boston, MA Licensure and Certification: 2006-present ‘Limited License Commonwealth of Massachusetts Board of Registration in Medicine Professional Societies: 2005-present NARAL Pro-Choice America, 2005-present NARAL Pro-Choice Massachusetts 2006-preseat American College of Obstetrics and Gynecology, Junior Fellow 2009-present Massachusetts Medical Society Awards and Honors: 2009-present Administrative Chief Resident Brigham and Women's Hospital/Massachusetts General Hospital Integrated Residency in Obstetrics and Gynecology (44 residents) gg orezreo St2 Fh09/91/2010 WED 12:22 FAX 6172771440 ‘opcyn 2008 Pitcher-Garrett Award: support for travel to Norway to investigate healthcare delivery and family planning services in a national healthcare system. 2007 ‘Harvard Medical Students Teaching Award, ‘Obstetrics and Gynecology, Brigham and Women’s Hospital 2004 Alpha Omegs Alpha 2003-2005 Clerkship Honors: Medicine, Surgery, Obstetrics and Gynecology, Psychiatry, Primary Care, Emergency Medicine, Maternal-Fetal Medicine, Rehabilitation and Physical Medicine. Northwestern University Feinberg Schoo) of Mediciné, Chicago, 1 2000 Steere Prize for Best Women’s Studies Senior Essay ‘Yale University, New Haven, CT (Comamnitvees/Organizations: 2009-presemt Resident Education Committee Brigham and Women’s/Massachusctts General Integrated Residency in Obstetrics and Gynecology 2007-preseat Boston Area-Wide Farnily Planning Group 2001-2005 ‘Medical Students for Choice 2001-2005 ‘American Medical Women’s Association PARTIE: Research, Teaching and Clinical Contribution; ‘Teaching of Students ia Courses 2006-present Obstetics and Gynecology Clerkship, Harvard Medical School: Formal and informa! teaching including Gynecology moming rounds, OB chief morning rounds and surgical teaching Brigham and Women's Hospital and Massachusetts General Hospital 2005 Physical Diagnosis course: ‘Medical Student Teaching Assistant ‘Northwestern University Feinberg School of Medicine Formal Teaching and Presentations 2009 Late Pregnancy Termination; Legal and Ethical Issues Ob/Gyn Grand Rounds, Brigham and Women's Hospital 2008 Controversies in Contraception: does BMI matter? Ob/Gyn Grand Rounds, Brigham and Women's Hospital 2008 ‘Heterotopic pregnancy Gynecology Conference, Brigham and Women’s Hospital03/91/2010 NED 12:22 FAX 6172771440 oncyn 2007 2007 2005 Research Activity 2008-present 2006-present 2002 ‘Uterine Perforation Associated with Pregnancy Termination Gynecology Conference, Brigham and Women’s Hospital Not Your Average Ectopic: Ovarian Ectopic Pregnancy Ob/Gyn Grand Rounds, Massachusetts General Hospital ‘Ob/Gyn Grand Rounds, Salem Hospital Pain Management in Fire-Trimester Abortion Ob/Gyn Grand Rounds, Massachusetts General Hospital IUD malpositioning: risk factors, outcomes and future pregnancies ‘Case control study Poster accepted for presentation at Association of Reproductive Health Professionals annual meeting 2009 Fetal movement ln pregnancies with liveborn infants Cross-sectional survey of postpartum women at BWH/MGH Project ongoing Correlation between personality profiles and satisfaction surveys of ‘women undergoing medical and surgical abortion Study design and IRB submission Northwestern University Feinberg School of Medicine Edncation of Patients and Service to the Community 2005-present ‘NARAL Pro-Choice Massachusetts Participation in advocacy events 1998 ‘Anti-Sexual Abuse Project Performer, presenter and teacher to high schoo! and college students Previous Employment 2005-2006 Quality Assurance Associate Planned Parenthood League of Massachusetts 2005-2006 ‘Brigham and Women’s Hospital 2005-2006 Research Associate and Interventionist Departinent of Psychiatry Brigham and Women's Hospital 2000-2001 ‘Health Education Coordinator g ‘ g03/31/2010 WED 12:22 FAX 8172771440 once American Heart Association ~ Rocky Mountain Division ® 1999-2000 Health Education end Marketing Intern g Planned Parenthood of Connecticut 8 6 PART III: Bibliography 1, Brasten, KP. The abortion counseling service Jane; its public health significance [Masters thesis). Chicago (IL): Northwestern Univer.: 2008, 2. Braaten KP, and Laufer MR. Human Papillomavirus (HPV), HPV-related disease, and HPV vaccine. Reviews in Obstetrics and Gynecology 2008;1;1: 2-10. 3. Brasteo K, Briegleb C, Hauke S, Niamkey N, Chang, G. Screening Pregnant Young Adults for Alcohol and Drug Use: A Pilot Study. Jounal of Addiction Medicine 2008; 2:74-78. 4, Shah AD, Massagli MP, Kobli N, Rajan SS, Bramten KP, Hoyte 1. A reliable and valid instrument to assess patient knowledge about urinary incontinence and pelvic organ prolapse. International Urogynecology Journal Including Pelvic Floor Dysfimction 2008; 19(9):1283-9.CURRICULUM VITAE PA eral Information 3 g § DATE PREPARED: March 17, 2010 ‘Name: Kari Patricia Braaten, MD, MPH Office Address: Department of Obstetrics and Gynecology Brigham and Women’s Hospital 75 Francis Street Boston, MA.02115 Home Address: E-Mail: Place of Birth: Oslo, Norway Education: 2001-2005 MD __ Feinberg Schoo! of Medicine, Northwestem University, Chicago, IL. 2001-2005 MPH Northwestem University. Chicago, IL 1996-2000 BA Women’s Studies, Yale University, New Haven, CT Post-doctoral training: 2006-2010 Obstetrics and Gynecology Residency Brigham and Women’s & Massachusetts General Hospitals, Boston, MA Commonwealth of Massachusetts Board of Registration in Medicine Professional Societies: 2005-present ‘NARAL Pro-Choice America 2005-present NARAL Pro-Choice Massachusens 2006-present ‘American College of Obstetrics and Gynecology, Junior Fellow 2009-present Massachusetts Medical Society Awards and Honors: 2009-present Administrative Chief Resident Brigham and Women’s Hospital/Massachusetts General Hospital integrated Residency in Obstetrics and Gynecology (44 residents)2008 Pitcher-Garrett Award: support for travel to Norway to investigate healthcare delivery and family planning services in a national healthcare system. 2007 Harvard Medical Students Teaching Award, Obstetrics and Gynecology, Brigham and Women's Hospital 2004 Alpha Omega Alpha 2003-2005 Clerkship Honors: Medicine, Surgery, Obstetrics and Gynecology, Psychiatry, Primary Care, Emergency Medicine, Matemal-Fetal Medicine, Rehabilitation and Physical Medicine. Northwestern University Feinberg School of Medicine, Chicago, IL 2000 Steere Prize for Best Women’s Studies Senior Essay ‘Yale University, New Haven, CT ‘Committees/Organizations: 2009-present Resident Education Committee Brigham and Women’ s/Massachusetts General Integrated Residency in ‘Obstetrics and Gynecology 2007-presemt Boston Area-Wide Family Planning Group 2001-2005 Medical Students for Choice 2001-2005 American Medical Women’s Association PART Ik: Research, Teaching and Clinical Contribution: ‘Teaching of Students in Courses 2006-present 2005 ‘Obstetrics and Gynecology Clerkship, Harvard Medical School: Formal and informal teaching including Gynecology morning rounds, OB chief morning rounds and surgical teaching, Brigham and Women’s Hospital and Massachusetts General Hospital Physical Diagnosis course: Medical Student Teaching Assistant ‘Northwestern University Feinberg School of Medicine Formal Teaching and Presentations 2009 2008 2008 Late Pregnancy Termination, Legal and Ethical Issues Ob/Gyn Grand Rounds, Brigham and Women’s Hospital Controversies in Contraception: does BMI matter? ‘Ob/Gyn Grand Rounds, Brigham and Women’s Hospital Heterotopic pregnancy ‘Gynecology Conference, Brigham and Women’s Hospital2007 2007 2008 Research Activity 2008-present 2006-present 2002 Uterine Perforation Associated with Pregnancy Termination Gynecology Conference, Brigham and Women’s Hospital Not Your Average Ectopic: Ovarian Ectopic Pregnancy ‘Ob/Gyn Grand Rounds, Massachusetts General Hospital Ob/Gyn Grand Rounds, Satem Hospital Pain Management in First-Trimester Abortion ‘Ob/Gyn Grand Rounds, Massachusetts General Hospital TUD malpositioning: risk factors, outcomes and future pregnancies Case control study Poster accepted for presentation at Association of Repraductive Health Professionals annual meeting 2009 Fetal movement in pregnancies with livebom infants Cross-sectional survey of postpartum women at BWH/MGH Project ongoing Correlation betwoen personality profiles and satisfaction surveys of ‘women undergoing medical and surgical abortion Study design and IRB submission Northwestem University Feinberg School of Medicine Education of Patients and Service to the Community 2005-present NARAL Pro-Choice Massachusetts, Participation in advocacy events 1998 ‘Anti-Sexual Abuse Project Performer, presenter and teacher to high school and college students Previous Employment 2005-2006 Quality Assurance Associate Planned Parenthood League of Massachusetts 2005-2006 Research Assistant Division of Urogynecology Brigham and Women’s Hospital 2005-2006 Research Associate and Interventionist 2000-2001 Department of Psychiatry Brigham and Women's Hospital Health Edueation Coordinator onvezro 1z‘American Heart Association ~ Rocky Mountain Division 1999-2000 Health Education and Marketing Intern Planned Parenthood of Connecticut PART II: Bibliography 1, Braeten, KP. The abortion counseling service Jane; its public health si thesis]. Chicago (IL): Northwestern Univer.: 2005 ificance (Masters 2. Braaten KP, and Laufer MR. Human Papillomavirus (HPV), HPV-related disease, and HPV vaccine. Reviews in Obstetrics and Gynecology 2008;1;1: 2-10. 3. Braaten K, Briegleb C, Hauke S, Niamkey N, Chang, G. Screening Pregnant Young Adults for ‘Alcohol and Drug Use: A Pilot Study. Joumal of Addiction Medicine 2008; 2:74-78. 4. Shah AD, Massagli MP, Kohli N, Rajan SS, Brasten KP, Hoyte L. A reliable and valid instrument to assess patient knowledge about urinary incontinence and pelvic organ prolapse. ‘International Urogynecology Journal Including Pelvic Floor Dysfunction 2008; 19(9):1283-9,2 overt is g Full License Appt coHRECEIVED. 7 APR OBI Board of Registration in Medicine te 200 Harvard Mill Square, Sulte 330 Wakefield, MA 01880 engage . ‘Telephone: (761) 876-8210 Fax: (781) 876-8383 www.massmedboard.org, MEDICAL EDUCATION VERIFICATION Presse compet wale felt ontario ac areas oma your unverstyediat school) ‘Savery of gracuion fe verticaion, aodae to maa! eno tn blow to provi ryan Horn pedaling to my media eduction tour ett, -Aaslconte Siete: esi pinta Type Nene “DCaaten Kasi e Sect Saary Ne: Terre ay 7 7 tm Nas) —_ ane cftecau dene Morthideseen Oniseraty Feinbery Suro of Medians ‘Adireos_303 €. Cnicagn Ave. cy Chua Stas or Prove: JL |NSTRUCTIONS TO THE DSN GR OFSIONATED OFFICIN, OF VEDICAL SCHOO, ‘Pleese complete his torn and forward I, gets wth xcopy of he cal wanscrp (whic ndlates cours akan, ‘Gros end hour ot etandanca, and woores, grads, or evlurtona) and mal tothe Board ot Regiazeson In Macine APELGANTS EQUGATIONAL taSTORY Itname of easton wes anerent nar he sbove rare ataton when appar banded, please ere rare bee Pramedict! Education: oes your achoot have 8 premedical achool equcaton requirement? TS] Yes One yn setae pecan calmed pemaeat ect ‘Aaplcans Undergracvate Schoo “Yale “Tio weessty Uncrate Sch Aton (atin on page 2)3 pweeri0. Fall License Application = mart # (aw tne cana aay tantra rane) ‘wi 4 tended eur metal cal on he ftowing datos fate he month day and yer hte section bel: a ‘armmnpatice pares: mow 2m ROM wm setae, 95 ft ton 82106 J 08 BAO 105 Tare 95 10 oneiees pyres 5 Seen I anpptantardes [SS tat wntao-____timonna erst shea eatin a Hae ehaatenicaar stachons DB vas maced dese nDostor of Hestetee cn erty HAT | 20 12005 C_wes oT onrdad degroe. Please eso eaters Unusual Clenstnces: The elowirg queso anh lo usual creumstances fal ocued dung am. oe applants med! edison. beans mss. be some 2 x8 no. 1. Diet eptcan ake ay eves of sence or raha rom hse medal educadon? 2. as no appear ve placed ch tation? 1. Wat the apteare ever cinined or under investigation? “4 Were any nepuve eps eve! Sle by insur repre apart? ‘COMMENTS: -ABFIXINSTITUTIONAL SEAL HERE (¢fthe insvution doas net have a seal ths form must be ‘otarzed) INTERNATIONAL MEDICAL SCHOOLS MUST — pnt Name: [ATTACH A COPY OF THE MEDICAL SCHOOL DIPLOMA ‘AND A TRANSCRIPT OR PROVIDE AN EXPLANATION. Dee: 03 128/10. Telephone (312 )_503-1225 ‘This form will not be accepted unless itis stamped with the institutional seal or notarized.1 owze10 Board of Registration io Medicine 200 Harvard Mill Square, Suite 330 - Wakefield, MA 01880 ‘Telephone: (781) 876-8210 Fas: (781) 876-8383 | www.massmedboard.org te { POSTGRADUATE TRAINING VERIFICATION ] APPLICANTS AUTHORATION atone ne ese of eran fom my sora tiningwoyan ie bow regen 8 Dowd of Regaaton In Medne. Pane cole Os fom en foward 2 ho apaican a sealed enone. slgnsd across he anu. te deperoert was tz of “versions frogrem plese wor docuenan of be eben, dates ane hearst Pahis Name of sateen, Brighana 2\sbmen's Hnspttal $$$ name oitsson was kere when sopicant tended, plana ent’ nae: eovatinant ane Fmpnon: ow mewessean na Vari TAG) pence nbs iowa woe Aina Deis rans Aeeanes Progra type rox | peparmestor | (ONTDAYNEAR) | completed | ASEM. RSC, KOA anamatinresency, | 230 |opmotepedaty | gee ng | WeewO) | “ormat cored "asi Tne Internchip 1 | o@leyn [eltolos |sfsles | No | Agee. Iniernsnip 1 [Bley [Yalow foliar] Yes | Aceme Wesidency. 2 | eelevn lujzoor Mule | ves [aceme desidercy 3B [OB)eyn [lod [clalor| yes | Aceme Desdency fF | oaleyn [epolor felrilio [ proges| Acams (Centre on poye2)12 a-aarie a [POSTORADUATE VERIIEATION ORM PAGE 2” srrucanrs nave Kao P. Broaten ‘Unvautl Cheumstances: The faowing quests apply to unusual creamstanors Het occured dure an st! the apcats masal educaton. Ploee ree te aperture espanse. BYouanswer yes to any of these queslon, pase enone an explanation. SuEsTONS msn 1. Dist appcant eke ary eaves of baerce oy aks tom hima pos asusa vaning? 2, Was he aopleant ever placed on roto? |. was ne appcant eer pte or und ivesaon? 4. Were ary agate repos eve fed by net egaring te epoca? ‘5, Wry ay lntaters or specal raquremars imposes on the applic: bechise of ieslonsfacageme ompeterct er shay probers? 4, Owing ne spocanr parton ow pousranatamescaltaing G)-Cos acest by: BKCOME Chote, comuents es ‘cerncation: near cry ate woove itemaen CTE 6 he be omy knowl i Progam Drecors Soranre: LUTTE &. Hmrrc katona AFFIX INSTITUTIONAL SEAL HERE prnnane: Carte @ Trorrete Bete A the nattion does oot havea sea, paterictte RESdarna, Prater Direehr Seenmotts tte ty ae oe ‘Telephone: e Toeay's Dawe: 2) 21d rxsase hen ihn coumereD FoR TO THE APPLICANT WA SEALED ENVELOPED TH YOUR HONATURE ACROSS THE SEAI: OF THE ENVELOPE. aSUPPLEMENT FORM printName:_ Kari “Bracten pate: 2 111 A0/0 IMPORTANT NOTE: Ifyou answer “yes” to any of these questions, you must provide the additions! information on pages 4-10. QUESTIONS YES NO 1. Since your enrollment in college, have you been subject to any disciplinary action (see definition) at an academic institution? 2A, Have youever been terminated or granted a leave of absence by a medical school or any postgraduate training program or have you ever withdrawn from a medical school or any postgraduate training program or had to repeat a year of postgraduate training? 2-B, Have you ever, for any reason, been placed on probation by a medical school or any postgraduate training program? 3. Have you ever applied for licensure orto sit for an examination or taken an examination under different name? If so, previous name: 4. Since your enrollment in college, have you been denied the privilege of taking or finishing an ‘examination or been accused of cheating and/or improper conduct during an examination? 5, Have you ever failed any of the following examinations: FLEX, any State Board examination, ‘any part of the National Boards, any Step of the USMLE. NBOME. or have you failed to gain certification from the National Board of Medical Examiners, any other certification body or any (oreign licensing or cenification body? 6A. Have you ever, for any reason, been denied a medical license, whether full, imited, temporary, ‘or have you withdrawn an application for medical licensure? 6-B, Have you ever voluntarily surrendered a license 10 practi medicine or any healing art? 7. Have you ever, for any reason, lost American Board of Medical Specialty or been denied ‘required recertification by one or more specialty boards? BA. Are any formal disciplinary charges pending against you, or do you have knowledge of any pending investigation inta your professional competence or conduct by any governmental authority; health care facility, group practice or professional medical society or association (Gnternetional, national, state or local)? (See definition. 8B, Has any disciplinary action ever been taken against you for violation of laws, rules, by-laws, or standards of practice by any governmental authority, heatheare facility, group or professional medical society or association ( national, state or local)? Applian’ Sigrare Png ae 317 20/0 oLeereo Sz es9A, 9.8, 9c, oD, 2 uw ISA. 15.8, Applicant's Signature: gin pated, (1/2010 Have you ever voluntarily relinguished any medical staff membership? Has your medical staff membership, medical privileges or medica} staff status at any hospital been limited, suspended, revoked, not renewed o subject to probationary ‘conditions or has processing toward any of those ends been instituted or recommended by ‘a medical staff commintee or governing board? Have you ever been denied medical staff membership, or advancement in medical staff status, or has such denial been recommended by e standing medical staff commizee or ‘governing body? . Have you ever, for any reason, withdraven an application for hospital privileges or appointment? Have you ever been charged with any criminal offense, other than a minor traffic offense? Has your privilege to possess, dispense or prescribe contralled substances ever been “suspended revoked, denied, restricted or surrendered, or have you ever been called before ‘or warmed by any slate or other jurisdiction including a federal agency regarding such privileges? as any professional liebility insurance provider ever restricted, limited, terminated, imposed a surcharge or co-payment, or placed any condition related vo professional competency or conduct on your coverage or have you ever voluntarily restricted, limited or terminated your insurance coverage in response to any inquiry by a professional liability insurance provider? Have you ever been the subject of any suspension or probation proceedings instituted Blue Cross or Blue Shield, Medicare, Medicaid, or any other medical Reimbursement plan; or ‘have you ever been restricted from receiving payments from any Blue Cross or Blue ‘Shield, Medicare, Medicaid (any state), or third pany programs? Have you ever had an application for membership as a participating provider rejected by ‘any HMO/PPOMPA or other prepaid health care plan oF your contract as a participating provider terminated by any HMOJPPOMIPA or other prepaid plan? In the past ten (10) years, has eny medical malpractice claim been made against you, whether or not a lawsuit was filed in relation to the claim? In the past ten (10) years, has any lawsuit, other than a medical malpractice suit, which is ‘elated to your competency to practice medicine, or your professional conduct in the ‘practice of medicine, been filed against you or has such a suit been sertled, adjudicated or ‘otherwise resolved? oveeevo OFCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Kar P Braaten, M.D. License No 243646 Current Status: Active License Expiration Dat 4) Activity Status: Active 1212011 2) Address & Contact Information Mailing Address: Home Address: Business Address: 75 Francis Street Boston Massachusetts - 02115 United States of America (617) 732-8500 3) Email Address: 4) Fax Number: cialtes © SPeettes and Gynecoiogy 6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information ABMSIAOA Board Name Certification ‘Subspecialty None Reported 7) Drug License Numbers Massachusetts Federal (DEA) Federal (DEA) XS 8) Other states where you are now licensed to practice None Reported 9) States where you were previously licensed None Reported 10) Work Sites Ua ofall work sites in Massachusets, Inclucing health care feciities (where you are credentialed), private office, clinics, nursing homes, etc Worksite Location Brigham & Women's Hospital Page tot Date: Hs20%0 ‘ine: 2 pisses soz =Commonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Kati P Breaten, M.D, License No.: 243648 111) Care of patients in Massachusetts Average weekly hours involved in: a) inpatient care 2 hsv 'b) outpatient care 16 nreiwk 12) Medicat Ltabiuity Insurance Information Insurance Carrier Policy Start Date Policy End Date Policy Type RICO 9701/2010 1293172010 Claims made with tail coverage RICO 01012011 4231/2012 Claims made with iil coverage 13) Do you perform any surgery in your Massachusetts office? 14) Claims Made 2) New: Have you received notification of a claim, whether of not a lawsuit was filed on that claim, or has any mecical melorectice claim been made against you during this time period? ) Pending: Are there ary unresolved malpractice claims against you today, ie, any claims that have not ‘been resoNved, seltied or adjudicated during this time period? 18) Claims Closed Haas afty medical malpractice claim against you (whether or nol ¢ lawsuit was fled on that claim) been resolved, settled, or adjudicated during this lime period? 16) Other Civil Lawsults . ‘Question 16 refers to claims or actions related to your competency to practice medicine or your professional conduct in the practice of medicine. 3) New. Have there been ary claims, oer than medical malpractce clas, tled against you during this ime perio b) Resolved: Have you resolved, settled or adjudicated any lawsuits, other than medics! malpractice claims, curing this period? 47) Criminal Charges a) Have you been charged with any criminal offense during this period? b) Have any criminal offensesicharges against you been resolved during this time period? (0) Are there anyy criminal charges pending against you today? 4) Are any Application of Issuance of Process pending against you? 18) Other Issues a) Have you withdrawn an application to ary governmental authority, health care tacity, group practice employer or professional association? b)Have you ever taken a leave of absence from any health care facity, group practice ot employer? €) Have You been the subject of an investigation by any governmental guaity, heath care faciy, Qioup paste, employe or rolestianal ossadaion? oy Have you been the subject of disciplinery action teken by ery governmental authorly, healthcare facility, group practice, employer or professionel association? 18) Have your privileges to possess, dispense of prescribe controlled substances been suspended, Fevoked, denied, restricted by or surrendered to any state or federal agency? 20) Have you withdrawn an application for a medical license, allowed a license application to become obsolete or have you been denied a medical license for any reason? 21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge ‘or co-payment, or placed any condition related to. professional competency or conduct on your ‘coverage, or have you voluntarily restricted, limited or terminated your insurance coverage In response to an Inquiry by a medical liability insurance carrier? Page 2 ot 4 ae: 11182010 “Time: 2:09 PMRCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Kari P Braaten, M.D. License No: 243648 22) Have you completed all CME requirements (100 hours of CME of which 10 hours must be in risk management. Requirement: 49 hours creditin Category 1 and 89 hours in Category 2) for ths renewal period? (It you are in an approved Residency! Fellowship program, or if your are renewing your license for the first time, please answer Yes) 25) Do you have a medical concition that interferes In any way or limits your ablity to practice icine’ 24) Have you used any chemical substances) which in any way interferes with your ability to practice medicine’ 3b Date: 14572010 ‘Tim: 2:09 PmCommonwealth of Massachusetts @) Board of Registration in Medicine Physician Renewal Application Physician Name: Kari P Braaten, M.D, License No.: 243646 ‘Compliance with Legal Responsibilities Online profile: {[B]! have reviewed my Physician Profile and confirm that the information is accurate, 4) J understand and agree to comaly with my abigations o report abuse or neglect of chicten pursuant to ) (iSite 118 see SA and unsersiana tre punstmert for fae To Samp. |understancend agree 1 comay wth my ebigations fo report ebuse of neglect of dleabed perzons 7) purssanlto GL 18 see TO an | uncersiand the puneryert fr falure 0 Comp. 3) Lunderstanc and ape to comply win my obligations to epor abuse, neglect or Financial expotaton of elderly persons pursuart to M.G.L. ¢. 19A sec. 18 and | understand the punishment for failure to comply. 4) understand ang agree to comaly with my obligation to repo ine treatment ol wounds, bums end other injuries pursuant io MG.L. c. 112 sec. 12A and! understand the punishment for failure fo comply. '8) understand and agree to comsty with my obligations to report the treatment of victims of rape or sexual assault pursuant to M.G.L. c. 112 sec, 12A 1/2 end | understand the punishment for failure to compl. 6) Lunderstan and agree to comly with my obligations to report physica tothe Soard of Medicine pursuant » Tale 1120s oe, when fave’ reasonable base eleve iat a pareon toate ary provelons ot MOL 6. t12see Sor ny Boarc equation 7) |understand and agree to ‘with my obligations related to charging and collecting fees from Medicare beneficiaries in accordance with the Medicare fee schedule, pursuant to M.G.L.c, 112sec. 2. 8) Lunderstand end have complied with my obligations to fle Massechusets tax returns and to pey Massechusetis laxes and | understand that, pursuant to M.G.L.¢. 62C sec. 49A, my license shall not be issued or renewed unless | make this cerfication under penatties of pefjury. 9) | understand and agree to comaly with my obligations relate to the reporting ofthe wages of employees ) nd contacts puscartio MeL e626 See 10)! understand and agree to comply with my obligations celated to the withholding and remitting of child ‘support payments pursuant 10 W.G.L. ©. 119A. 11)! understand and agree to comely with my cbiigations to file an Incident Repor withthe Board when certain ‘adverse everis occur in my otvate office, pursuant Io M.G.Lc. 112 sec, 5 and 243 CMR 3.00 ei seq. and! Understand that the Patient Care Assessment (PCA) programs at the health care facilities where | practice Teport certain Major Incidents tothe Boar 42)| understand and agree to comply with my obligations to disclose ownership interest in any partnership, corporaiion, frm or other legal entity to which | have relerred a patient for prysical therapy services, Pursuant to'M.G.L ¢. 112 see. 12) 19) am aware of my obigalions and responsibilities under the Health ingurance Portablity and Accountability ‘Act of 1996 (Hi luding the requirement that | oblain and provide to the Board a National Provider: Identifier (NPI) nu 114)|understang and am in compilance with HIPAA and ail other federal and state obigations placed upon me 28 a physician. 18)| understand that as an applicant for a license renewal to practice medicine a criminal record check may be ‘Conducted for conviction and pending criminal case information only from the Criminal History Systems. Board and that it will not necessarily disqualty me. [have reviewed the above statements and certify that | understand my requirement to comply with the responsibilities and obligations of each and agree to do so. BH _ Under penalties of perjury, | declare that | have examined this renewal application and allot its accompanying instructions, forme and sttemonts, and tothe best of my knowledge and belt, ‘certify thatthe information Contained herein is true, accurate, and complete. Paged of Date: ts72010 ‘Time: 2:08 PIMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Kari ? Beaten, M.D License No: 243645 Current Status: Aciive License Expiration Date: 1/12/2013 4) Activity Status: Active 2) Address 8 Contact Information Mailing Address: Home Address: Business Address: Brigham and Women’s Hospital 850 Boylston Street Chestnut Hill Massachusetts - 02467 United States of America (617) 732-8300 3) Email Address: 4) Fax Number: (617) 525-7748 5) Specialties Gynecokogy 6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information ABMS/AOA Board Name Certification ‘Subspeciaity None Reported 7) Drug License Numbers Massachusetts Federal (DEA) Federal (DEA) XS 8) Other states where you are now licensed to practice None Reported 9) States where you were previously licensed Nong Reported 10) Work Sites Uist of all work sites in Massachusetts, including heath care facilities (where you are credentialed), priv office, clinics, nursing homes, ett Worksite Location Brigham & Women's Hospital Page t of Dato: 1202012 ‘Time: 9:18 aMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Kari P Braaten, MO License No.: 243646 11) Care of patients in Massachusetts Average weekly hours involved in: a) inpatient care 1 hisiwk bb) outpatient care 18 hrsiwic 12) Medical Liability Insurance Information Insurance Carrier Policy Start Date PolicyEnd Date Policy Type RICO 01/18/2012 123172012 Claims made with tail coverage CRICG 0170172013 1208172013 Claims made with tail coverage 13) Do you perform any surgery in your Massachusetts office? 14) Claims Made 2) New. Have you received notification of 2 claim, whether or not a lawsult was fled on that claim, oF has ‘any medical malpractice claim been made against you during this ime perioc? b) Pending: Are there any unresolved malpractice claims against you today, 1e., any claims that have not been resalved, settled o” adjudicated during this time period? 18) Claims Closed Has any medical malpractice claim against you (whether or not 2 lawsuit was filed on that claim) been resolved, settied, oF adjudicated during this time period? 1) Other Civil Lawsuits ‘Question 16 refers fo claims or actions related to your compete! professional conduct in the practice of medicine. a} New Have there been ary Ciaims, other tan mecical maipractice ure period? by Resolves Have you resolved, settled or adjudicated any lawsuits, other than medical malpractice claims, during th's period? to practice mecicine or your ims, fled against you during this 417) Criminal Charges 2) Have you been charged with ary criminal offense during this period? 5) Have Sny criminal affenses/charges against you been resolved during this time peniog? ©} Ae there any crimina’ charges penaing against you today? ) Are any Application of Issuance of Process pending against you? 18) Other Issues. 2) Have you withdrawn an application to any governmental authority, health care facility, group practice ‘employer oF professional association? bb) Have you ever taken a leave of absence from any health care facilty, croup practice or employer? 6} Have you been the subject of an investigation by any governmental authoaly. including the Massachusells Soard of Registration in Mecicine or ary other stale medical boarc, nealtn care feciity, ‘group practice, empioyer oF professional association?” ) Have you been tne subject of a disciplinary action taken by any governmental authority, health care facility, group practice, employer or professional association? 49) Have your privileges to possess, dispense or prescribe controlled substances been suspended, revoked, denied, restricted by or surrendered to any state or federal agency? 20) Have you withdrawn an application for a medical license, allowed a license application to become obsolete or have you been denied a medical license for any reason? 21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge oF co-payment, or placed any condition related to professional competency or conduct on your coverage, or have you voluntarily restricted, limited or terminated your insurance coverage in response to an inquiry by a medical liability insurance carrier? Page 2 of 6 ate: 13202012 ‘rime: 9:18 AM‘Commonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Kari PBraaten, MO: License No.: 243646 22) Have you completed all CPD requirements (100 hours of CPD of which 10 hours must be in risk management, Requirement: 40 hours ereditin Category 1 and 69 hours n Category 2) for this Yes renewal period? (if you are in an approved Residency! Fellowship program, or if your are renewing your license for the first time, please answer Yes) Page Sof 8 Date: 1202012 Time: 9:18 AltCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Applicati Physician Name: Kari P Biaaten, MD License No.: 2 28) Do you have a medical condition that interferes in any way or limits your ability to practice medicine? 24) Have you used any chemical substance(s) which in any way interferes with your ability to practice medicin Pages of 6 Date: 14zar2002 “Timo: 8:18 AMCommonwealth of Massachusetts Physician Name: Kari P Braaien, M.O- License No.: 243646 Current Status: Active License Expiration Date: 1/12/2015 4) Activity Status: Active 2) Address & Contact Information Mailing Address: Home Address: Business Address: Brigham and Women's Hospital Boylston Street Chestnut Hill Massachusetts - 02467 United States of America (617) 732-8300 3) Email Addres: 4) Fax Number: (617) 525-746 © gras 6) Current American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) Information ABMSIAOA Board Name Certification ‘Subspecialty ABMS ‘Obstetrics & Gynecology Obstetrics and Gynecology 7) Drug License Numbers Massachusetts Federal (DEA) Federal (DEA) XS 8) Other states where you are now licensed to practice None Reported 9) States where you were previously licensed None Reported 10) Work Sites List of all work sites in Massachusetts, inciucing health care facilities (where you are credentialed), private office, clinics, nursing homes, etc WorkSite Location. Brigham & Women’s Hospital Page 1 of 8 Date: 12712014 Time: 41:24 AMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Kari P Braaten, MD. License No.: 243646 Physician Nar 14) Care of patients in Massachusetts ‘Average weekly hours involved in: a) inpatient care 1 hrs/wk 'b) outpatient care 19 hrs/wk 42) Medical Liability Insurance Information Insurance Carrier Policy Start Date PolicyEndDate —_—Policy Type RICO. OVo1/2014 12/31/2014 Claims made with tail coverage RICO 0101/2018 1213172015 Claims made with tail coverage 13) Do you perform any surgery in your Massachusetts office? 14) Claims Made S)New: Mave you received notiication of a claim, whether or not 2 lawsuit was fied on that claim, or has Any medical malpractice claim been made against you during thi time period? bp} Pending. Ave there any unresolved malpractice claims against you today, ie, any claims that have not been resolved, settled or adjudicated during this time period? 18) Claims Closed Flas any medical malpractice claim against you (whether or not a lawsuit was filed on that clalin) been resolved, settied, or adjudicated during this time period? 16) Other Civil Lawsuits Question 16 refers to claims or actions related to your competency to practice medicine or your professional conduct in the practice of medicine. 2} New: Hav there been ary clair, other tan medical malprectie lars filed against you during this time peri by Resolved: Have you resolved, settled or adjudicated any lawsuits, ether than medical malpractice claims, during this period? 17) Criminal Charges a) Have you been charged with any criminal offense during this perioc? 1B} Have Sny cnminal offenses/charges against you been resolved during this time perioc? (9) Are there anyy criminal charges pending against you today? 1 Are any Application of Issuance of Process pending against you? 18) Other tssues Fave you wthorawn an appication to any governmental authorty, health care facility, group practice ‘employer or professional association? by Have fou taken a leave of absence from any health care fecity, group practice or employer for reasons related fo your competence to practice medicine? «) Have you beer the subject oan vestigation by ary governmental autorty, clr tre Mesedchusetts Board of Registration in Medicine or ary other state medical board, health care facity, yOup_ practice, employer or professional association? 0) Pave you been the subject ofa disciplinary action taken by any governmental authorty, health care facity, group practice, employer or professional association? 49) Have your privileges to possess, dispense or prescribe controlled substances been suspended, revoked, denied, restricted by of surrendered to any state or federal agency? 20) Have you withdrawn an application for a medical ticense, allowed a license application to becotte obsolete or have you been denied a medical license for any reason? 21) Has any medical liability insurance carrier restricted, limited, terminated, imposed a surcharge ‘or co-payment, or placed any condition related to professional competency or conduct on your coverage, or have you voluntarily restricted, limited or terminated your insurance coverage in Tesponse to an inquiry by a medical liability insurance carrier? Page? ot Date: 122014 Tien 11:34 AMLCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Kari P Braaten, M.D. License No.: 243646 22) Have you completed all of the CPD requirements for this renewal cycle? If you are renewing your license for the first time or participating in postgraduate training, please answer Yes. Yes Page 3 of 6 Date: 12h2014 Time: 11:34 AMCommonwealth of Massachusetts Board of Registration in Medicine Physician Renewal Application Physician Name: Kari P Braaien, M.D. License No.: 243646 22) Do you have a medical condition that interferes in any way or limits your ability to practice medicine? 24) Have you used any chemical substanco(s) which in any way interferes with your ability to practice medicine’ Pages of 8 ate: 42/1/2014 Time: 11:34 AM